Impact of a Health Intervention on Some Indicators in the Care of Chronic Complex Patient (CCP).

Sponsor

María José del Olmo Rubio (Other)

Overall Status

Completed

CT.gov ID

NCT03091036

Collaborator

Hospital Universitario 12 de Octubre (Other)

Enrollment

Location

Arm

18.1

Duration (Months)

1.5

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

The aim of this study is to assess the effectiveness of proactive and integrated healthcare program for chronic complex patients (CCP). This program are based in coordination the primary level of attention with and speciality level. The objective is reducing hospital readmissions and know the benefit in total cost of care in 4 month before and 4 after intervention.

Condition or Disease	Intervention/Treatment	Phase
Preventive Care	Other: Proactive healthcare intervention	N/A

Detailed Description

Quasi-experimental study with single-arm (pre-post study design without control group). The investigators checking pre and post intervention the effectiveness of a healthcare program for CCP. The interventions consist:

- Help the nurse in the hospital to carry out the care plans and the continuity care report.
- Refer patients to the social workers.
- Collaborate with the social worker to refer to centers of media, long stay and reference hospital.
- Ensure the follow-up appointments for the CCP.
- Make proactive calls to the CCP and/or their caregiver after discharge
- Plan the hospital discharge 48 hours in advance, so that the family and the patient can be organized.

The investigator analysed if with this program, the CCP reducing hospital readmission and reducing the Hospital expenditure.

Study Design

Study Type:

Interventional

Actual Enrollment :

28 participants

Allocation:

N/A

Intervention Model:

Single Group Assignment

Masking:

None (Open Label)

Primary Purpose:

Prevention

Official Title:

Impact of a Proactive and Integrated Health Intervention Between Different Assistance Levels Over Some Indicators in the Care of Chronic Complex Patient (CCP)

Study Start Date :

Jul 1, 2015

Actual Primary Completion Date :

Jul 1, 2016

Actual Study Completion Date :

Jan 1, 2017

Arms and Interventions

Arm	Intervention/Treatment
Other: Proactive healthcare intervention Participants who were included before (single-arm pre-post study), now a proactive and integrated intervention program for the health is performed of the complex chronic patient, based in an improvement of the care process.	Other: Proactive healthcare intervention There is an intervention in the coordination of health resources, and monitoring readmissions and know the benefit in total cost of care in 4 month.

Arm

Intervention/Treatment

Other: Proactive healthcare intervention

Participants who were included before (single-arm pre-post study), now a proactive and integrated intervention program for the health is performed of the complex chronic patient, based in an improvement of the care process.

Other: Proactive healthcare intervention

There is an intervention in the coordination of health resources, and monitoring readmissions and know the benefit in total cost of care in 4 month.

Outcome Measures

Primary Outcome Measures

Pre-post change in days of Hospital stay from baseline to 16 weeks. [Baseline and 16 weeks.]
The same group of patients are analyzed the days of hospital stay at the end of 16 weeks of follow-up pre intervention (baseline) and 16 week after the intervention.

Secondary Outcome Measures

Number of hospital readmissions visits for CCP change from baseline to 16 weeks. [Baseline and 16 weeks.]
The same group of patients are analyzed the number of hospital readmissions visit for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.
Number of urgency visits for CCP change from baseline to 16 weeks. [Baseline and 16 weeks.]
The same group of patients are analyzed the number of urgency visits and primary care visit for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.
Number of primary care visits for CCP change from baseline to 16 weeks. [Baseline and 16 weeks.]
The same group of patients are analyzed the number of primary care visits for CCP at the end of 16 weeks pre intervention (considered baseline) of follow-up and 16 weeks after the intervention.

Eligibility Criteria

Criteria

Ages Eligible for Study:

75 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Patient ≥ 75 years.
Having attended 5 or more emergency visits or having had more than 3 hospital admissions in the last 12 months.
Identified with social risk alert.

Exclusion Criteria:

Participate in other health programs (AHT, diabetes mellitus,...).
Terminal patient.

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Hospital Universitario 12 de Octubre de Madrid	Madrid		Spain	28041

Sponsors and Collaborators

María José del Olmo Rubio
Hospital Universitario 12 de Octubre

Investigators

Principal Investigator: María José del Olmo Rubio, Hospital 12 de Octubre de Madrid

Study Documents (Full-Text)

None provided.

More Information

Publications

None provided.

Responsible Party:

María José del Olmo Rubio, Principal investigator, Hospital Universitario 12 de Octubre

ClinicalTrials.gov Identifier:

NCT03091036

Other Study ID Numbers:

InveCuidPCC16

First Posted:

Mar 27, 2017

Last Update Posted:

Apr 10, 2017

Last Verified:

Apr 1, 2017

Individual Participant Data (IPD) Sharing Statement:

Plan to Share IPD:

Studies a U.S. FDA-regulated Drug Product:

Studies a U.S. FDA-regulated Device Product:

Keywords provided by María José del Olmo Rubio, Principal investigator, Hospital Universitario 12 de Octubre

Chronic

Complex

Study Results

No Results Posted as of Apr 10, 2017